S-4070-119
Read twice and referred to the Committee on Finance.
Sponsored by Todd Young (R-IN)
What it does
This bill would make two changes to federal health programs for people with diabetes. First, it would require Medicaid to recognize doctors of podiatric medicine (foot and ankle specialists) as "physicians" for purposes of covering their services, ensuring states must cover podiatric care under Medicaid. Second, it would update Medicare's documentation requirements for therapeutic diabetic shoes, replacing the current standard with a more detailed but streamlined set of criteria — including documented peripheral neuropathy, foot deformity, prior ulceration or amputation, or poor circulation — that a physician must attest to before shoes are covered.
Who benefits
Medicaid enrollees with diabetes who need foot and ankle care, particularly in states that currently do not cover podiatric services. Doctors of podiatric medicine (DPMs), who would gain formal "physician" recognition under Medicaid and potentially see increased patient volume. Medicare beneficiaries with diabetes who may find it easier to qualify for therapeutic shoes under the updated documentation standard. Pedorthists and orthotists who fit and furnish diabetic shoes, as clearer eligibility criteria may reduce claim denials. Patients in rural or underserved areas where podiatrists may be the primary accessible foot care provider.
Who is hurt
State Medicaid programs that do not currently cover podiatric services would face new mandatory coverage obligations and associated costs, requiring legislative or regulatory action in some states. Federal and state budgets would bear increased spending on newly covered podiatric services. Physicians who currently hold a monopoly on certifying diabetic shoe eligibility may face increased competition from podiatrists. Durable medical equipment suppliers who benefit from the current, more restrictive shoe documentation standard may see changes to their patient base or claim patterns.
Supporters argue
Supporters argue that diabetes-related foot complications — including ulcers, infections, and amputations — are among the most costly and preventable consequences of the disease, with lower-extremity amputations costing Medicare an estimated $11 billion annually. They contend that excluding podiatric physicians from Medicaid's physician definition creates an arbitrary barrier to specialized foot care for low-income patients, and that modernizing the diabetic shoe documentation standard removes bureaucratic obstacles that delay medically necessary equipment without improving clinical oversight.
Opponents argue
Opponents argue that expanding mandatory Medicaid coverage to podiatric services imposes new unfunded obligations on state budgets already under fiscal pressure, potentially crowding out other Medicaid priorities. They contend that loosening the documentation threshold for diabetic shoes — by replacing a single treating physician's order with a broader attestation framework — could increase the risk of fraud and improper payments in the durable medical equipment sector, which the HHS Office of Inspector General has repeatedly identified as a high-risk area for Medicare billing abuse.
Constitutional context
Congress uses its Taxing and Spending Clause authority (Art. I, §8, cl. 1) to fund Medicaid and Medicare and attach conditions to that funding. Under NFIB v. Sebelius (2012), spending conditions are permissible so long as they do not cross into unconstitutional coercion — a threshold the Court found was crossed when the ACA threatened to strip all existing Medicaid funding. This bill adds a new coverage mandate to state Medicaid plans but includes a grace period for states requiring legislative action, which is a standard mechanism used to reduce coercion concerns.
Checks and balances
Congress gains authority by expanding mandatory Medicaid coverage requirements on states; the Secretary of HHS retains implementation and enforcement authority, and states retain some flexibility through the legislative grace period provision.
Historical precedent
Medicare has recognized podiatric physicians as physicians under Title XVIII since 1987; this bill extends analogous recognition to Medicaid under Title XIX, closing a longstanding definitional gap between the two programs.